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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":32550.99,"maximum":84707.81,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32550.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":84707.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67765.65},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48017.45},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81264.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":19647.61,"maximum":51129.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19647.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51129.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40903.0},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28983.09},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49050.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":28730.05,"maximum":74764.54,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28730.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":74764.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59811.1},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42381.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71725.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":17611.15,"maximum":45829.69,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17611.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45829.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36663.43},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25979.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43966.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":12976.92,"maximum":33769.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12976.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33769.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27015.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19142.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32397.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":66147.78,"maximum":172137.15,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66147.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":172137.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":137708.49},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97577.62},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165140.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":10791.21,"maximum":28082.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10791.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28082.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22465.47},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15918.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":7210.36,"maximum":18763.6,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7210.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18763.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15010.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10636.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":13279.74,"maximum":34558.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13279.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34558.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27646.17},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19589.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33153.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":8541.69,"maximum":22228.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8541.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22228.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17782.35},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12600.23},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21324.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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","minimum":18996.55,"maximum":49434.94,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18996.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49434.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39547.6},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28022.67},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47425.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15003.65,"maximum":39044.17,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15003.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39044.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31235.06},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22132.57},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37457.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27768.59,"maximum":72262.53,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27768.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72262.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57809.51},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40962.72},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69325.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11464.98,"maximum":29835.45,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11464.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29835.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23868.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16912.52},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28622.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":64278.95,"maximum":167273.86,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64278.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":167273.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":133817.9},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94820.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160474.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":43898.09,"maximum":114236.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43898.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":114236.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":91388.39},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64756.07},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109593.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":26488.1,"maximum":68930.28,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26488.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68930.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55143.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39073.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66128.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":45094.22,"maximum":117349.22,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45094.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":117349.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93878.54},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66520.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112579.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15961.86,"maximum":41537.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15961.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41537.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33229.89},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23546.07},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39849.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2160.84,"maximum":5623.17,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2160.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":5623.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":4498.5},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3187.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5394.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7291.47,"maximum":18974.68,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7291.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18974.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15179.61},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10755.98},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":20950.16,"10th_percentile":20950.16,"90th_percentile":20950.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11318.98,"maximum":29455.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11318.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29455.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23564.2},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16697.14},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28258.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15187.5,"maximum":39522.62,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15187.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39522.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31617.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22403.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37916.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9930.33,"maximum":25841.82,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9930.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25841.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20673.27},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14648.69},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24791.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10966.41,"maximum":28538.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10966.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28538.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22830.21},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16177.05},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27378.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","code_information":[{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51958.5,"maximum":135212.22,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51958.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":135212.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":108168.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76646.36},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129716.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy Without Cc/Mcc","code_information":[{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9996.3,"maximum":26013.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9996.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26013.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20810.61},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14746.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24956.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11718.05,"maximum":30494.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11718.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30494.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24395.0},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17285.83},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29254.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7368.26,"maximum":19174.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7368.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19174.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15339.47},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10869.26},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18395.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15971.59,"maximum":41563.06,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15971.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41563.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33250.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23560.42},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39873.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8541.69,"maximum":22228.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8541.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22228.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17782.35},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12600.23},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21324.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":15620.52,"10th_percentile":15620.52,"90th_percentile":15620.52,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":5883.36,"maximum":15310.34,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5883.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15310.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12248.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8678.81},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14688.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5600.47,"10th_percentile":5600.47,"90th_percentile":5600.47,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3161.25,"10th_percentile":3161.25,"90th_percentile":3161.25,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":13716.66,"maximum":35695.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13716.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35695.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28555.77},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20234.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34244.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8431.37,"maximum":21941.06,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8431.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21941.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17552.69},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12437.5},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21049.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"1 through 10","median_amount":16604.75,"10th_percentile":16604.75,"90th_percentile":16604.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17296.43,"maximum":45010.7,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17296.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45010.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36008.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25514.75},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43181.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10119.6,"maximum":26334.34,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10119.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26334.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21067.29},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14927.88},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25263.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7018.94,"maximum":18265.46,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7018.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18265.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14612.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10353.95},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17523.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":25900.84,"maximum":67402.07,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25900.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67402.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53921.17},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38207.52},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64662.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16369.58,"maximum":42598.76,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16369.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42598.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34078.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24147.52},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40867.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12379.93,"maximum":32216.44,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12379.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32216.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25772.92},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18262.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30906.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"1 through 10","median_amount":24448.11,"10th_percentile":24448.11,"90th_percentile":24448.11,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7866.83,"maximum":20471.95,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7866.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20471.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16377.41},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11604.72},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19639.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11042.12,"maximum":28735.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11042.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28735.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22987.82},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16288.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27567.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5567.71,"10th_percentile":5567.71,"90th_percentile":5567.71,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5681.35,"10th_percentile":5681.35,"90th_percentile":5681.35,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18200.56,"maximum":47363.54,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18200.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47363.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37890.49},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26848.48},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45438.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":8833.56,"10th_percentile":8833.56,"90th_percentile":8833.56,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":25925.72,"maximum":67466.8,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25925.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67466.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53972.96},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38244.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64724.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"1 through 10","median_amount":36560.59,"10th_percentile":36560.59,"90th_percentile":36560.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":26800.35,"10th_percentile":26800.35,"90th_percentile":26800.35,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":26336.86,"10th_percentile":26336.86,"90th_percentile":26336.86,"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":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49711.15,"maximum":129363.9,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49711.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":129363.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":103490.2},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73331.18},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124105.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17328.87,"maximum":45095.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17328.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45095.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36075.78},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25562.61},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43262.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":26434.02,"maximum":68789.56,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26434.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68789.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55031.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38994.03},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65993.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":53938.73,"maximum":140365.39,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53938.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":140365.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112291.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79567.48},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":134659.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":34720.48,"maximum":90353.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34720.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90353.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72282.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51217.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86680.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":229550.54,"maximum":597362.03,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":229550.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":597362.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":477885.38},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338620.47},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":573080.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":149802.89,"maximum":389833.8,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149802.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":389833.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":311864.27},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":220981.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":373987.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":111508.06,"maximum":290178.71,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111508.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":290178.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":232140.91},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164490.62},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":278383.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":50149.16,"maximum":130503.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50149.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":130503.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104402.06},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73977.31},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125199.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":140056.41,"maximum":364470.43,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140056.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":364470.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":291573.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":206603.61},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":349655.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":57252.45,"maximum":148988.71,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57252.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":148988.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":119189.91},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84455.7},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142932.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":34363.58,"maximum":89424.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34363.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89424.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71539.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50691.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85789.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":61973.19,"maximum":161273.56,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61973.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":161273.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":129017.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91419.49},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154718.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":42307.2,"maximum":110096.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42307.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":110096.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88076.43},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62409.28},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105621.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":6782.99,"10th_percentile":6782.99,"90th_percentile":6782.99,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":49172.56,"maximum":127962.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49172.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":127962.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102368.95},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72536.69},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122760.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":33626.0,"maximum":87505.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33626.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":87505.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70003.64},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49603.24},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83948.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27285.16,"maximum":71004.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27285.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":71004.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56803.09},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40249.59},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68118.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":36896.45,"maximum":96016.07,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36896.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":96016.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76812.17},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54427.64},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92113.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":23741.09,"maximum":61781.71,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23741.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61781.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49424.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35021.56},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59270.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":48456.61,"maximum":126099.19,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48456.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":126099.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":100878.46},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71480.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120973.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5603.77,"10th_percentile":5603.77,"90th_percentile":5603.77,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":23778.94,"maximum":61880.21,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23778.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61880.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49503.73},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35077.4},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59364.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11026.97,"maximum":28695.62,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11026.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28695.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22956.29},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16266.39},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27529.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14011.91,"maximum":36463.37,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14011.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36463.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29170.43},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20669.61},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34981.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9947.64,"maximum":25886.85,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9947.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25886.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20709.3},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14674.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24834.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":29818.04,"maximum":77595.82,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29818.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":77595.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62076.11},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43985.95},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74441.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19004.12,"maximum":49454.64,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19004.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49454.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39563.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28033.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47444.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15182.1,"maximum":39508.55,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15182.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39508.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31606.56},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22395.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37902.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21748.97,"maximum":56597.58,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21748.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56597.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45277.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32082.89},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54297.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":11362.7,"10th_percentile":11362.7,"90th_percentile":11362.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10926.39,"maximum":28433.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10926.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28433.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22746.9},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16118.02},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27278.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7401.79,"maximum":19261.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7401.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19261.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15409.27},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.71},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18478.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15883.99,"maximum":41335.09,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15883.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41335.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33067.78},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23431.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39654.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9348.49,"maximum":24327.67,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9348.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24327.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19461.97},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13790.38},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23338.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8639.02,"maximum":22481.43,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8639.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22481.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17984.98},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12743.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21567.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18004.81,"maximum":46854.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18004.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46854.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37482.97},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26559.72},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44949.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11096.19,"maximum":28875.74,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11096.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28875.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23100.39},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16368.5},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27702.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8178.3,"maximum":21282.49,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8178.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21282.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17025.84},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12064.19},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20417.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17350.5,"maximum":45151.42,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17350.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45151.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36120.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25594.52},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43316.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11148.1,"maximum":29010.84,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11148.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29010.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23208.46},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16445.07},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27831.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":20737.76,"maximum":53966.12,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20737.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53966.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43172.51},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30591.22},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51772.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8924.54,"maximum":23224.43,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8924.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23224.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18579.38},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13164.99},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22280.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19575.15,"maximum":50940.64,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19575.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50940.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40752.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28876.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48870.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9685.91,"maximum":25205.77,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9685.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25205.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20164.43},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24181.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":24718.76,"maximum":64325.93,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24718.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64325.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51460.28},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36463.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61711.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15095.58,"maximum":39283.4,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15095.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39283.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31426.44},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22268.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37686.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10336.98,"maximum":26900.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10336.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26900.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21519.84},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15248.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25806.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":24570.6,"maximum":63940.35,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24570.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":63940.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51151.83},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36245.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61341.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11881.36,"maximum":30919.0,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11881.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30919.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24734.98},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17526.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29662.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8902.91,"maximum":23168.14,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8902.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23168.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18534.35},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13133.09},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22226.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27894.05,"maximum":72589.0,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27894.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72589.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58070.69},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41147.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69638.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27894.05,"maximum":72589.0,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27894.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72589.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58070.69},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41147.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69638.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":39061.62,"maximum":101650.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39061.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101650.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81319.68},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57621.57},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97518.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":24819.34,"maximum":64587.67,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24819.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64587.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51669.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36612.15},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61962.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14734.36,"maximum":38343.39,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14734.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38343.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30674.44},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21735.32},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36784.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures With Mcc","code_information":[{"code":"100","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20946.49,"maximum":54509.3,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20946.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54509.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43607.05},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30899.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52293.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9761.62,"maximum":25402.77,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9761.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25402.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20322.04},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14399.81},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24370.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16599.94,"maximum":43198.23,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16599.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43198.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34558.27},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24487.33},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41442.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16148.96,"maximum":42024.62,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16148.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42024.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33619.4},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23822.06},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40316.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9584.25,"maximum":24941.21,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9584.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24941.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19952.79},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14138.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23927.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Cc","code_information":[{"code":"141","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23588.6,"maximum":61384.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23588.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61384.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49107.47},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34796.62},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58889.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17265.07,"maximum":44929.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17265.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44929.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35942.95},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25468.49},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43102.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","code_information":[{"code":"143","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40519.48,"maximum":105444.31,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40519.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":105444.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84354.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59772.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101158.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":13751.27,"maximum":35785.1,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13751.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35785.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28627.82},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20285.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34330.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8620.64,"maximum":22433.58,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8620.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22433.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17946.71},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12716.69},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21521.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. 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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":32189.77,"maximum":83767.8,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32189.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":83767.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67013.65},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47484.59},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80362.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14855.48,"maximum":38658.6,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14855.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38658.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30926.6},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21914.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37087.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8706.08,"maximum":22655.92,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8706.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22655.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18124.58},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12842.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21735.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16900.6,"maximum":43980.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16900.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43980.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35184.19},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24930.85},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42192.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"1 through 10","median_amount":13835.85,"10th_percentile":13835.85,"90th_percentile":13835.85,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10555.44,"maximum":27468.54,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10555.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27468.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21974.64},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15570.81},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26352.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16545.87,"maximum":43057.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16545.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43057.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34445.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24407.57},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41307.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11508.24,"maximum":29948.03,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11508.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29948.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23958.21},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16976.33},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28730.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7756.52,"maximum":20184.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7756.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20184.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16147.76},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11441.99},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19364.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":13360.85,"maximum":34769.1,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13360.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34769.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27815.03},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19709.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33355.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":26550.2,"10th_percentile":26550.2,"90th_percentile":26550.2,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11979.78,"maximum":31175.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11979.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31175.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24939.87},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17671.91},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29907.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":45680.56,"10th_percentile":45680.56,"90th_percentile":45680.56,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":15712.79,"10th_percentile":15712.79,"90th_percentile":15712.79,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"1 through 10","median_amount":5567.74,"10th_percentile":5567.74,"90th_percentile":5567.74,"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."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9117.05,"maximum":23725.39,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9117.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23725.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18980.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13448.97},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22761.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":10737.7,"10th_percentile":10737.7,"90th_percentile":10737.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6943.23,"maximum":18068.45,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6943.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18068.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14454.63},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10242.28},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17334.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14215.24,"maximum":36992.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14215.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36992.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29593.72},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20969.54},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35488.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":22120.43,"10th_percentile":22120.43,"90th_percentile":22120.43,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8715.81,"maximum":22681.25,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8715.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22681.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18144.84},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12857.09},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21759.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6797.23,"maximum":17688.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6797.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17688.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14150.68},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10026.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16969.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":22973.79,"10th_percentile":22973.79,"90th_percentile":22973.79,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":20410.07,"maximum":53113.36,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20410.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53113.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42490.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30107.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50954.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10264.52,"maximum":26711.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10264.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26711.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21368.99},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15141.66},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25625.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7745.7,"maximum":20156.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7745.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20156.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16125.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11426.04},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19337.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19078.74,"maximum":49648.83,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19078.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49648.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39718.71},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28143.92},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47630.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11888.93,"maximum":30938.7,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11888.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30938.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24750.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17537.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29681.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7733.81,"maximum":20125.77,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7733.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20125.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16100.48},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11408.49},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19307.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10503.53,"maximum":27333.45,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10503.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27333.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21866.57},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15494.23},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26222.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7246.05,"maximum":18856.48,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7246.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18856.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15085.05},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10688.98},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18090.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":10531.24,"10th_percentile":10531.24,"90th_percentile":10531.24,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":117603.39,"maximum":306040.67,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117603.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":306040.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":244830.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173482.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":293600.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":61720.12,"maximum":160614.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61720.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":160614.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":128490.85},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91046.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154086.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":107684.96,"maximum":280229.81,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107684.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":280229.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":224181.86},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":158850.99},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268839.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","code_information":[{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":105800.98,"maximum":275327.12,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105800.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":275327.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":220259.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156071.86},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":264135.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","code_information":[{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71111.87,"maximum":185055.24,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71111.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":185055.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":148042.88},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104900.36},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":177533.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","code_information":[{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71111.87,"maximum":185055.24,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71111.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":185055.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":148042.88},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104900.36},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":177533.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","code_information":[{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83040.81,"maximum":216098.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83040.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":216098.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":172876.92},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122497.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207314.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":53506.13,"maximum":139239.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53506.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":139239.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111390.71},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78929.34},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133579.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16163.02,"maximum":42061.21,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42061.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33648.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23842.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40351.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":37725.96,"maximum":98174.72,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37725.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":98174.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78539.07},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55651.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94184.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":28071.41,"maximum":73050.57,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28071.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":73050.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58439.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41409.42},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70081.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":15631.02,"10th_percentile":15631.02,"90th_percentile":15631.02,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19269.09,"maximum":50144.16,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19269.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50144.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40114.98},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28424.71},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48105.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":29172.38,"maximum":75915.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29172.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":75915.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60731.96},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43033.51},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72829.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18362.79,"maximum":47785.7,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18362.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47785.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38228.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27087.79},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45843.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","code_information":[{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11812.14,"maximum":30738.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11812.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30738.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24590.88},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17424.63},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29489.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":33065.78,"maximum":86047.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33065.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":86047.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":68837.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48776.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82549.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":36128.59,"maximum":94017.85,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36128.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":94017.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75213.61},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53294.93},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90196.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":39130.83,"maximum":101830.62,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39130.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101830.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81463.77},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57723.68},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97691.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":66278.65,"maximum":172477.69,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66278.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":172477.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":137980.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97770.66},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165466.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":51488.05,"maximum":133987.96,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51488.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":133987.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":107189.41},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75952.37},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128541.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":74384.49,"maximum":193571.62,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74384.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":193571.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":154855.92},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109727.95},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185703.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":38461.38,"maximum":100088.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38461.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100088.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80070.09},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56736.14},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96020.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27610.7,"maximum":71851.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27610.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":71851.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57480.8},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40729.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68931.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6477.1,"maximum":16855.44,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6477.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":16855.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13484.23},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9554.67},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16170.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23931.43,"maximum":62277.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23931.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62277.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49821.19},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35302.35},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59745.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11573.13,"maximum":30116.89,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11573.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30116.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24093.3},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17072.05},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28892.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":29267.55,"maximum":76163.29,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29267.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":76163.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60930.09},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43173.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73067.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Cc","code_information":[{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18460.12,"maximum":48038.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18460.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48038.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38430.85},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27231.37},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46086.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":16953.48,"10th_percentile":16953.48,"90th_percentile":16953.48,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis Without Cc/Mcc","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10054.71,"maximum":26165.48,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10054.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26165.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20932.2},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14832.15},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25101.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13884.3,"maximum":36131.27,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13884.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36131.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28904.76},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20481.36},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34662.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9181.94,"maximum":23894.26,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9181.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23894.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19115.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13544.69},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22923.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6121.29,"maximum":15929.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6121.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15929.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12743.49},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9029.79},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15282.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16891.95,"maximum":43958.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16891.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43958.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35166.18},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24918.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42171.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7280.66,"maximum":18946.54,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7280.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18946.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15157.1},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10740.03},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18176.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12869.85,"maximum":33491.36,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12869.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33491.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26792.85},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18984.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32130.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8166.41,"maximum":21251.53,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8166.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21251.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17001.08},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12046.64},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20387.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17042.28,"maximum":44349.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17042.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44349.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35479.14},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25139.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42546.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders Without Mcc","code_information":[{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9876.26,"maximum":25701.1,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9876.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25701.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20560.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14568.92},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24656.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6122.37,"maximum":15932.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6122.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15932.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12745.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9031.39},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15284.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7591.05,"maximum":19754.27,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7591.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19754.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15803.28},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11197.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18951.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9426.35,"maximum":24530.31,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9426.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24530.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19624.07},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13905.24},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23533.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10418.09,"maximum":27111.12,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10418.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27111.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21688.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15368.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26009.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7376.91,"maximum":19197.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7376.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19197.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15357.48},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10882.02},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18416.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":72314.5,"maximum":188184.86,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72314.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":188184.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":150546.55},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106674.42},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180535.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":26196.09,"maximum":68170.4,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26196.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68170.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54535.83},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38643.05},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65399.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":48266.26,"maximum":125603.86,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48266.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":125603.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":100482.19},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71199.77},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120498.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":26013.32,"maximum":67694.76,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26013.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67694.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54155.33},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38373.43},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64943.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":29425.45,"maximum":76574.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29425.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":76574.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":61258.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43406.83},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73461.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":39157.87,"maximum":101900.98,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39157.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101900.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81520.06},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57763.56},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97758.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":25330.89,"maximum":65918.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25330.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65918.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52734.63},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37366.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63239.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16601.03,"maximum":43201.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16601.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43201.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34560.53},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24488.93},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41445.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":27932.98,"maximum":72690.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27932.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72690.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58151.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41205.22},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69735.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15118.29,"maximum":39342.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15118.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39342.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31473.72},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22301.68},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37743.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":37188.46,"maximum":96775.96,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37188.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":96775.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77420.08},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54858.39},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92842.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":26110.65,"maximum":67948.06,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26110.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67948.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54357.96},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38517.02},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65186.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":43481.71,"maximum":113152.95,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43481.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":113152.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":90521.56},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64141.85},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108553.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Cc","code_information":[{"code":"412","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22738.54,"maximum":59172.76,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22738.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59172.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47337.79},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33542.65},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56767.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. Without Cc/Mcc","code_information":[{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17958.31,"maximum":46733.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17958.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46733.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37386.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26491.12},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44833.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38529.52,"maximum":100265.81,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38529.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100265.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80211.94},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56836.65},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96190.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","code_information":[{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22351.36,"maximum":58165.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22351.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58165.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46531.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32971.51},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55800.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":20141.36,"10th_percentile":20141.36,"90th_percentile":20141.36,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","code_information":[{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14744.09,"maximum":38368.72,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14744.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38368.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30694.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21749.68},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36809.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":9770.68,"10th_percentile":9770.68,"90th_percentile":9770.68,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25808.92,"maximum":67162.84,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25808.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67162.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53729.8},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38071.91},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64432.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","code_information":[{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18294.65,"maximum":47608.39,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18294.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47608.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38086.37},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26987.28},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45673.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14771.13,"maximum":38439.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14771.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38439.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30750.99},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21789.56},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36876.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"1 through 10","median_amount":19441.5,"10th_percentile":19441.5,"90th_percentile":19441.5,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":36847.79,"maximum":95889.42,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36847.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":95889.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76710.86},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54355.85},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91991.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18791.06,"maximum":48900.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18791.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48900.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39119.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27719.55},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46912.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4942.32,"10th_percentile":4942.32,"90th_percentile":4942.32,"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":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. 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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. 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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16225.74,"maximum":42224.44,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16225.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42224.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33779.25},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23935.34},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40508.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12232.85,"maximum":31833.68,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12232.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31833.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25466.72},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18045.23},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30539.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9228.44,"maximum":24015.28,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9228.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24015.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19212.05},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13613.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23039.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17630.61,"maximum":45880.35,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17630.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45880.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36703.95},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26007.72},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44015.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9097.58,"maximum":23674.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9097.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23674.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18939.62},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13420.25},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22712.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5576.22,"10th_percentile":5576.22,"90th_percentile":5576.22,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6720.44,"maximum":17488.68,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6720.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17488.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13990.82},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9913.63},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16777.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":27980.89,"10th_percentile":27980.89,"90th_percentile":27980.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19409.68,"maximum":50510.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19409.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50510.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40407.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28632.11},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48456.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10439.72,"maximum":27167.4,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10439.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27167.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21733.73},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15400.11},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26063.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7567.26,"maximum":19692.36,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7567.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19692.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15753.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11162.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18891.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18070.78,"maximum":47025.81,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18070.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47025.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37620.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26657.04},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45114.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11835.94,"maximum":30800.79,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11835.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30800.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24640.42},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17459.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29548.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":32332.81,"10th_percentile":32332.81,"90th_percentile":32332.81,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8947.25,"maximum":23283.53,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8947.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23283.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18626.66},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13198.5},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22337.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":72261.5,"maximum":188046.95,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72261.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":188046.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":150436.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106596.24},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180403.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":64490.93,"maximum":167825.49,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64490.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":167825.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":134259.2},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95133.51},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161003.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":45126.67,"maximum":117433.65,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45126.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":117433.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":93946.09},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66568.41},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112660.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":24611.7,"maximum":64047.3,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24611.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64047.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51237.39},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36305.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61443.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":29978.1,"maximum":78012.35,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29978.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":78012.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62409.33},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44222.06},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74841.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":34901.09,"maximum":90823.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34901.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90823.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72658.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51484.19},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87131.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22615.25,"maximum":58851.92,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22615.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58851.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47081.12},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33360.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56459.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16938.45,"maximum":44079.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16938.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44079.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35262.99},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24986.68},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42287.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21700.3,"maximum":56470.94,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21700.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56470.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45176.35},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32011.1},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54175.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22488.71,"maximum":58522.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22488.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58522.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46817.69},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33174.12},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56143.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17903.15,"maximum":46589.58,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17903.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46589.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37271.33},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26409.75},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44695.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17026.05,"maximum":44307.1,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17026.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44307.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35445.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25115.91},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42506.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11056.17,"maximum":28771.61,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11056.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28771.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23017.08},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16309.47},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27602.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":34466.32,"maximum":89692.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34466.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89692.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71753.05},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50842.85},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86046.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22474.65,"maximum":58486.05,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22474.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58486.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46788.42},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33153.38},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56108.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16619.41,"maximum":43248.88,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16619.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43248.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34598.8},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24516.05},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41490.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":40418.9,"maximum":105182.57,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40418.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":105182.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84145.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59623.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100907.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21632.16,"maximum":56293.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21632.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56293.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45034.5},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31910.59},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54005.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16156.53,"maximum":42044.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16156.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42044.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33635.16},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23833.23},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40335.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":31041.21,"maximum":80778.91,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31041.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":80778.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64622.55},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45790.31},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77495.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22902.93,"maximum":59600.55,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22902.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59600.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47680.02},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33785.15},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57177.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21302.31,"maximum":55435.24,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21302.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55435.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44347.8},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31424.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53181.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14019.48,"maximum":36483.07,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14019.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36483.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29186.19},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20680.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35000.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8515.73,"maximum":22160.59,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8515.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22160.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17728.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12561.94},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21259.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19104.7,"maximum":49716.38,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19104.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49716.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39772.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28182.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47695.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11117.82,"maximum":28932.03,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11117.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28932.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23145.42},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16400.4},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27756.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14019.48,"maximum":36483.07,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14019.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36483.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29186.19},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20680.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35000.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8977.53,"maximum":23362.33,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8977.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23362.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18689.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13243.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22412.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8982.94,"maximum":23376.41,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8982.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23376.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18700.96},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13251.14},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22426.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16080.82,"maximum":41847.31,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16080.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41847.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33477.55},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23721.56},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40146.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9659.96,"maximum":25138.22,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9659.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25138.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20110.4},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14249.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24116.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":14880.12,"10th_percentile":14880.12,"90th_percentile":14880.12,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":20168.89,"maximum":52485.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20168.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52485.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41988.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29752.06},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50352.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9684.83,"maximum":25202.95,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9684.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25202.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20162.18},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14286.54},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24178.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16694.03,"maximum":43443.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16694.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43443.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34754.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24626.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41677.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12397.23,"maximum":32261.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12397.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32261.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25808.94},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18287.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30950.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":24073.18,"10th_percentile":24073.18,"90th_percentile":24073.18,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18649.39,"maximum":48531.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18649.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48531.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38824.87},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27510.56},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46558.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":23151.67,"maximum":60247.86,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23151.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60247.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48197.86},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34152.09},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57798.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":20863.22,"maximum":54292.59,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20863.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54292.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43433.69},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30776.28},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52085.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":20930.27,"maximum":54467.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20930.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54467.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43573.28},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30875.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52253.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12829.83,"maximum":33387.23,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12829.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33387.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26709.54},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18925.87},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32030.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9374.44,"maximum":24395.22,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9374.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24395.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19516.0},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13828.67},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23403.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8321.06,"maximum":21653.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8321.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21653.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17323.04},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12274.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20773.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11264.9,"maximum":29314.79,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11264.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29314.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23451.62},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16617.37},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28123.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6543.08,"maximum":17027.12,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6543.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17027.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13621.58},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9651.99},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16335.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15371.36,"maximum":40001.07,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15371.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40001.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32000.57},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22674.99},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38375.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":25420.2,"10th_percentile":25420.2,"90th_percentile":25420.2,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9418.78,"maximum":24510.61,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9418.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24510.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19608.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13894.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23514.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":22965.28,"10th_percentile":22965.28,"90th_percentile":22965.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"1 through 10","median_amount":7827.54,"10th_percentile":7827.54,"90th_percentile":7827.54,"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 Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"1 through 10","median_amount":30113.29,"10th_percentile":30113.29,"90th_percentile":30113.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":10620.08,"10th_percentile":10620.08,"90th_percentile":10620.08,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15920.76,"maximum":41430.78,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15920.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41430.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33144.33},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23485.44},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39746.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9906.54,"maximum":25779.9,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9906.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25779.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20623.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14613.59},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24732.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16365.26,"maximum":42587.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16365.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42587.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34069.7},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24141.14},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40856.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders Without Mcc","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9802.72,"maximum":25509.72,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9802.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25509.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20407.6},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14460.43},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24472.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures With Cc/Mcc","code_information":[{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23704.32,"maximum":61686.02,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23704.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61686.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49348.38},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34967.32},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59178.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures Without Cc/Mcc","code_information":[{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15133.43,"maximum":39381.9,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15133.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39381.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31505.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22324.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37781.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"616","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37716.23,"maximum":98149.39,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37716.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":98149.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78518.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55636.93},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94159.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient 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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"617","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20227.29,"maximum":52637.72,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20227.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52637.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42109.8},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29838.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50498.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15338.91,"maximum":39916.64,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15338.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39916.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31933.02},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22627.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38294.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9692.4,"maximum":25222.65,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9692.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25222.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20177.94},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14297.71},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24197.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":26550.2,"10th_percentile":26550.2,"90th_percentile":26550.2,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6718.28,"maximum":17483.05,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6718.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17483.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13986.32},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9910.44},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14444.51,"maximum":37589.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14444.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37589.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30071.03},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21307.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36061.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8416.23,"maximum":21901.66,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8416.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21901.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17521.17},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12415.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21011.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":10547.44,"10th_percentile":10547.44,"90th_percentile":10547.44,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"1 through 10","median_amount":21000.93,"10th_percentile":21000.93,"90th_percentile":21000.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15380.01,"maximum":40023.58,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15380.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40023.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32018.58},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22687.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38396.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17802.57,"maximum":46327.84,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17802.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46327.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37061.94},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26261.39},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44444.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":45440.3,"maximum":118249.83,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45440.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":118249.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94599.02},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67031.07},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113443.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":25291.96,"maximum":65817.56,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25291.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65817.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52653.58},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37309.32},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63142.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17751.74,"maximum":46195.56,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17751.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46195.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36956.12},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26186.4},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44317.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16017.02,"maximum":41681.26,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16017.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41681.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33344.72},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23627.43},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39987.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9471.78,"maximum":24648.52,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9471.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24648.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19718.64},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13972.25},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23646.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6492.24,"maximum":16894.84,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6492.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":16894.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13515.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9577.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16208.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19507.02,"maximum":50763.33,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19507.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50763.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40610.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28775.69},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48699.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11331.96,"maximum":29489.28,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11331.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29489.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23591.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16716.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28290.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8547.09,"maximum":22242.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8547.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22242.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17793.6},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12608.21},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21338.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12548.64,"maximum":32655.48,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12548.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32655.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26124.15},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18511.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31328.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5567.72,"10th_percentile":5567.72,"90th_percentile":5567.72,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient 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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14540.77,"maximum":37839.61,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14540.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37839.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30271.42},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21449.75},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36301.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8454.09,"maximum":22000.16,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8454.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22000.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17599.98},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12471.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21105.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12370.2,"maximum":32191.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12370.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32191.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25752.66},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18247.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30882.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":28406.75,"10th_percentile":28406.75,"90th_percentile":28406.75,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7451.54,"maximum":19391.22,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7451.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19391.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15512.84},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10992.1},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18603.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11656.41,"maximum":30333.6,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11656.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30333.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24266.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17194.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29100.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17892.34,"maximum":46561.43,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17892.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46561.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37248.82},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26393.8},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44668.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":32606.38,"10th_percentile":32606.38,"90th_percentile":32606.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10977.23,"maximum":28566.16,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10977.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28566.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22852.73},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16193.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27405.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":24515.48,"10th_percentile":24515.48,"90th_percentile":24515.48,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient 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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","code_information":[{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7461.27,"maximum":19416.55,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7461.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19416.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15533.1},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.46},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18627.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21633.24,"maximum":56296.44,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21633.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56296.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45036.75},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31912.19},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54008.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16592.37,"maximum":43178.52,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16592.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43178.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34542.51},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24476.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41423.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14551.58,"maximum":37867.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14551.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37867.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30293.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21465.7},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36328.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":38658.22,"maximum":100600.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38658.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100600.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80479.87},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57026.5},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96511.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22285.39,"maximum":57993.53,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22285.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57993.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46394.41},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32874.19},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55636.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15881.83,"maximum":41329.46,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15881.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41329.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33063.28},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23428.01},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39649.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":38747.98,"maximum":100834.32,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38747.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100834.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80666.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57158.92},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96735.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19570.82,"maximum":50929.38,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19570.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50929.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40743.14},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28869.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48859.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15423.27,"maximum":40136.16,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15423.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40136.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32108.64},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22751.57},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38504.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19843.36,"maximum":51638.61,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19843.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51638.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41310.52},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29271.85},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49539.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":13418.17,"maximum":34918.26,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13418.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34918.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27934.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19793.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33498.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22161.02,"maximum":57669.87,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22161.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57669.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46135.49},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32690.73},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55325.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12302.06,"maximum":32013.8,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12302.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32013.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25610.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18147.33},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30712.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18786.74,"maximum":48888.94,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18786.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48888.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39110.81},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27713.17},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46901.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16204.11,"maximum":42168.16,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16204.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42168.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33734.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23903.43},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40454.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7891.71,"maximum":20536.68,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7891.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20536.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16429.2},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11641.41},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19701.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":74751.12,"maximum":194525.7,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74751.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":194525.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":155619.18},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110268.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":186618.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21008.14,"maximum":54669.72,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21008.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54669.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43735.39},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30990.06},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52447.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"1 through 10","median_amount":15930.12,"10th_percentile":15930.12,"90th_percentile":15930.12,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11066.99,"maximum":28799.76,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11066.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28799.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23039.6},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16325.42},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27629.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":41798.89,"maximum":108773.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41798.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":108773.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87018.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61659.46},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104352.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Adjustment Reaction And Psychosocial Dysfunction","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10384.56,"maximum":27023.87,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10384.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27023.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21618.9},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15318.74},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25925.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10175.83,"maximum":26480.69,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10175.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26480.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21184.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15010.84},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25404.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11613.15,"maximum":30221.03,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11613.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30221.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24176.61},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17131.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28992.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21265.53,"maximum":55339.55,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21265.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55339.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44271.24},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31369.76},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53090.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":15106.39,"maximum":39311.54,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15106.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39311.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31448.95},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22284.13},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37713.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22444.37,"maximum":58407.24,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22444.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58407.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46725.38},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33108.71},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56033.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11581.78,"maximum":30139.41,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11581.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30139.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24111.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17084.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28914.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Procedures For Injuries With Mcc","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41522.03,"maximum":108053.26,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41522.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":108053.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":86441.84},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61251.04},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103661.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21578.09,"maximum":56152.91,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21578.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56152.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44921.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31830.82},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53870.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14196.85,"maximum":36944.63,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14196.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36944.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29555.44},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20942.42},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35442.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":17678.2,"maximum":46004.18,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17678.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46004.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36803.02},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26077.92},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44134.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9576.68,"maximum":24921.51,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9576.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24921.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19937.03},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14127.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23908.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"1 through 10","median_amount":5019.56,"10th_percentile":5019.56,"90th_percentile":5019.56,"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":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18186.5,"maximum":47326.95,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18186.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47326.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37861.22},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26827.74},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45403.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16962.25,"maximum":44141.05,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16962.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44141.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35312.53},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25021.78},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42346.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":19800.1,"maximum":51526.04,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19800.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51526.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41220.46},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29208.03},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49431.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10839.87,"maximum":28208.73,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10839.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28208.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22566.78},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15990.39},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27062.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":7445.05,"maximum":19374.33,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7445.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19374.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15499.33},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10982.53},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18586.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":18919.76,"maximum":49235.11,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18919.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49235.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39387.74},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27909.4},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47233.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":11006.43,"maximum":28642.15,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28642.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22913.52},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16236.08},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27477.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":230905.66,"maximum":600888.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":230905.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":600888.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":480706.51},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":340619.47},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":576463.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":77572.75,"maximum":201868.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77572.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":201868.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":161493.34},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114431.1},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":193662.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":34832.95,"maximum":90646.2,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34832.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90646.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72516.31},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51383.68},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86961.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":42115.77,"maximum":109598.36,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42115.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":109598.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":87677.91},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62126.9},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105143.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":23907.64,"maximum":62215.13,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23907.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62215.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49771.66},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35267.25},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59686.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":22278.9,"maximum":57976.64,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22278.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57976.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46380.9},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32864.62},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55620.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":39242.23,"maximum":102120.5,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39242.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":102120.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81695.68},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57888.0},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97969.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":25273.57,"maximum":65769.71,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25273.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65769.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52615.3},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37282.2},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63096.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":21929.58,"maximum":57067.59,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21929.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57067.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45653.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32349.32},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54747.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":13728.56,"maximum":35725.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13728.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35725.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28580.54},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20251.63},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34273.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":8657.41,"maximum":22529.27,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8657.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22529.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18023.26},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12770.94},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21613.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":12866.61,"maximum":33482.92,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12866.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33482.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26786.1},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18980.12},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32121.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6788.58,"maximum":17665.99,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6788.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17665.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14132.67},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10014.14},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16947.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":6013.14,"maximum":15648.06,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6013.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15648.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12518.34},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8870.26},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15012.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":72796.85,"maximum":189440.08,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72796.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":189440.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":151550.72},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107385.95},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":181739.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":40696.85,"maximum":105905.87,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40696.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":105905.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84723.95},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60033.77},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101601.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Mcc","code_information":[{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":82409.22,"maximum":214454.47,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82409.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":214454.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":171562.05},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121565.6},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205737.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Procedures For Multiple Significant Trauma With Cc","code_information":[{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45573.33,"maximum":118596.0,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45573.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":118596.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94875.96},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67227.3},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113775.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Procedures For Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31840.44,"maximum":82858.75,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31840.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82858.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66286.41},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46969.29},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79490.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":16575.07,"maximum":43133.49,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16575.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43133.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34506.49},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24450.64},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41380.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":10171.51,"maximum":26469.43,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10171.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26469.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21175.36},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15004.45},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25393.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. 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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. 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Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","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: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":14005.43,"maximum":36446.48,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14005.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36446.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29156.93},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20660.04},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34965.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":9762.7,"maximum":25405.59,"payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9762.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25405.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20324.29},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14401.4},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24372.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 150000 | Total % of Charge: 55] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Neonatal (%BC): 60]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Services - Cost based: 101]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 20931 Days: 4 Additional Days: 2938] [Normal vag. Del. 4 day stay-Case Rate: 15281 Days: 4 Additional Days: 2938] [Normal Newborn-Per Diem: 1794] [Lower Level Neonate-Per Diem: 5316] [Higher Level Neonate-Per Diem: 10631] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [SNF-(% BC): 46] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5710.07] [Surgical-Per Diem: 5710.07]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 5881.37]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"20","median_amount":37.16,"10th_percentile":4.59,"90th_percentile":126.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"21","median_amount":43.7,"10th_percentile":36.42,"90th_percentile":170.46,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":3916.95,"10th_percentile":643.24,"90th_percentile":9192.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":60.74,"10th_percentile":35.67,"90th_percentile":913.31,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":33.07,"10th_percentile":33.07,"90th_percentile":42.87,"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."}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":171.51,"10th_percentile":171.51,"90th_percentile":171.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":111.51,"10th_percentile":111.51,"90th_percentile":111.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":379.31,"10th_percentile":336.73,"90th_percentile":409.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":294.37,"10th_percentile":294.37,"90th_percentile":294.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":267.61,"10th_percentile":267.61,"90th_percentile":267.61,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"17","median_amount":401.07,"10th_percentile":336.56,"90th_percentile":708.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"17","median_amount":301.92,"10th_percentile":228.96,"90th_percentile":639.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":308.93,"10th_percentile":308.93,"90th_percentile":308.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"15","median_amount":713.0,"10th_percentile":449.1,"90th_percentile":749.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"23","median_amount":860.64,"10th_percentile":579.41,"90th_percentile":1562.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"20","median_amount":496.17,"10th_percentile":236.04,"90th_percentile":1152.56,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"11","median_amount":111.51,"10th_percentile":96.96,"90th_percentile":324.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"217","median_amount":336.73,"10th_percentile":252.95,"90th_percentile":588.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"46","median_amount":370.4,"10th_percentile":251.98,"90th_percentile":547.36,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":335.5,"10th_percentile":335.5,"90th_percentile":335.5,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":458.06,"10th_percentile":458.06,"90th_percentile":458.06,"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":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"25","median_amount":572.84,"10th_percentile":331.68,"90th_percentile":1033.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":262.91,"10th_percentile":262.91,"90th_percentile":265.21,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":405.9,"10th_percentile":405.9,"90th_percentile":405.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"32","median_amount":632.99,"10th_percentile":263.41,"90th_percentile":1142.88,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"44","median_amount":441.51,"10th_percentile":291.41,"90th_percentile":762.77,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":719.05,"10th_percentile":376.78,"90th_percentile":1247.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"29","median_amount":1380.43,"10th_percentile":462.61,"90th_percentile":1870.55,"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":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"44","median_amount":1317.36,"10th_percentile":812.66,"90th_percentile":2279.68,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"26","median_amount":644.53,"10th_percentile":190.02,"90th_percentile":1226.4,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":197.38,"10th_percentile":197.38,"90th_percentile":197.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"39","median_amount":395.92,"10th_percentile":188.34,"90th_percentile":771.29,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"533","median_amount":550.81,"10th_percentile":336.73,"90th_percentile":865.82,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"107","median_amount":605.89,"10th_percentile":389.07,"90th_percentile":825.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":496.99,"10th_percentile":496.99,"90th_percentile":496.99,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"1 through 10","median_amount":336.73,"10th_percentile":336.73,"90th_percentile":336.73,"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":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":1275.05,"10th_percentile":1275.05,"90th_percentile":1275.05,"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":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"51","median_amount":851.88,"10th_percentile":324.85,"90th_percentile":1898.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"26","median_amount":478.58,"10th_percentile":302.78,"90th_percentile":883.5,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"12","median_amount":351.32,"10th_percentile":249.8,"90th_percentile":452.19,"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":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"43","median_amount":1426.93,"10th_percentile":488.41,"90th_percentile":2141.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"53","median_amount":1525.88,"10th_percentile":746.9,"90th_percentile":3323.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":1127.32,"10th_percentile":500.0,"90th_percentile":1830.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"22","median_amount":3650.4,"10th_percentile":1186.41,"90th_percentile":4563.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"26","median_amount":2768.61,"10th_percentile":1950.44,"90th_percentile":8074.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"25","median_amount":2216.86,"10th_percentile":851.57,"90th_percentile":4585.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2649.46,"10th_percentile":2649.46,"90th_percentile":2649.46,"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":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":1200.56,"10th_percentile":1200.56,"90th_percentile":1200.56,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"31","median_amount":990.11,"10th_percentile":410.54,"90th_percentile":3229.52,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"274","median_amount":969.66,"10th_percentile":396.52,"90th_percentile":2162.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"60","median_amount":1008.09,"10th_percentile":399.84,"90th_percentile":2375.11,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1100.67,"10th_percentile":1100.67,"90th_percentile":1418.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":1981.08,"10th_percentile":1981.08,"90th_percentile":1981.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"69","median_amount":2642.34,"10th_percentile":506.28,"90th_percentile":8854.94,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"46","median_amount":1515.98,"10th_percentile":443.88,"90th_percentile":4201.55,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"11","median_amount":655.29,"10th_percentile":417.76,"90th_percentile":2259.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"14","median_amount":2021.09,"10th_percentile":250.0,"90th_percentile":4000.77,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"58","median_amount":2012.04,"10th_percentile":1073.63,"90th_percentile":4701.13,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":1572.73,"10th_percentile":1110.87,"90th_percentile":4983.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":3234.4,"10th_percentile":2138.08,"90th_percentile":4563.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"15","median_amount":5885.05,"10th_percentile":3220.26,"90th_percentile":12360.79,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"11","median_amount":2807.99,"10th_percentile":1430.94,"90th_percentile":4321.08,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":3708.18,"10th_percentile":3708.18,"90th_percentile":4353.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"51","median_amount":2371.94,"10th_percentile":851.99,"90th_percentile":4121.06,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"82","median_amount":1133.44,"10th_percentile":497.6,"90th_percentile":2393.49,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"22","median_amount":1279.76,"10th_percentile":677.39,"90th_percentile":2974.14,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3018.4,"10th_percentile":1118.1,"90th_percentile":4635.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":3878.45,"10th_percentile":3878.45,"90th_percentile":3878.45,"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":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"30","median_amount":5020.38,"10th_percentile":1296.23,"90th_percentile":9819.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"43","median_amount":2107.98,"10th_percentile":1173.65,"90th_percentile":5632.31,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"26","median_amount":1710.08,"10th_percentile":1064.5,"90th_percentile":3309.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2006.95,"10th_percentile":2006.95,"90th_percentile":2006.95,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3025.81,"10th_percentile":3025.81,"90th_percentile":3025.81,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1792.97,"10th_percentile":1792.97,"90th_percentile":1792.97,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":5100.22,"10th_percentile":5100.22,"90th_percentile":5100.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":10218.2,"10th_percentile":10218.2,"90th_percentile":10218.2,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":6352.6,"10th_percentile":6352.6,"90th_percentile":6352.6,"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."}]}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":228.13,"10th_percentile":228.13,"90th_percentile":2025.5,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":2053.6,"10th_percentile":2053.6,"90th_percentile":2053.6,"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 Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":814.75,"10th_percentile":774.79,"90th_percentile":1690.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"15","median_amount":862.27,"10th_percentile":199.07,"90th_percentile":1772.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"16","median_amount":812.92,"10th_percentile":812.92,"90th_percentile":3250.0,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":894.21,"10th_percentile":894.21,"90th_percentile":4257.35,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":225.57,"10th_percentile":225.57,"90th_percentile":225.57,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":537.74,"10th_percentile":537.74,"90th_percentile":2304.05,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":228.13,"10th_percentile":228.13,"90th_percentile":258.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":7416.51,"10th_percentile":7416.51,"90th_percentile":7416.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":749.0,"10th_percentile":749.0,"90th_percentile":749.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1235.93,"10th_percentile":1235.93,"90th_percentile":1235.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":895.34,"10th_percentile":812.92,"90th_percentile":1490.35,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":894.21,"10th_percentile":894.21,"90th_percentile":894.21,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":6933.04,"10th_percentile":6933.04,"90th_percentile":6933.04,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":527.36,"10th_percentile":527.36,"90th_percentile":527.36,"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."}]}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":2056.98,"10th_percentile":2056.98,"90th_percentile":2056.98,"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 Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1175.34,"10th_percentile":1175.34,"90th_percentile":1175.34,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":300.0,"10th_percentile":300.0,"90th_percentile":300.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":10543.38,"10th_percentile":10543.38,"90th_percentile":10543.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":2921.69,"10th_percentile":2921.69,"90th_percentile":2921.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":351.56,"10th_percentile":351.56,"90th_percentile":351.56,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":386.72,"10th_percentile":386.72,"90th_percentile":386.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":211.46,"10th_percentile":211.46,"90th_percentile":211.46,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":6941.28,"10th_percentile":6941.28,"90th_percentile":8304.66,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5318.75,"10th_percentile":5318.75,"90th_percentile":5318.75,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4512.0,"10th_percentile":4512.0,"90th_percentile":5640.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":24823.75,"10th_percentile":24823.75,"90th_percentile":24823.75,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":11234.24,"10th_percentile":11234.24,"90th_percentile":11234.24,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6354.93,"10th_percentile":6354.93,"90th_percentile":7644.92,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4187.27,"10th_percentile":4187.27,"90th_percentile":4187.27,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":17610.85,"10th_percentile":17610.85,"90th_percentile":17610.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":13478.54,"10th_percentile":13478.54,"90th_percentile":13478.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5577.15,"10th_percentile":5577.15,"90th_percentile":5577.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":9984.0,"10th_percentile":9984.0,"90th_percentile":9984.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":16406.14,"10th_percentile":16406.14,"90th_percentile":24385.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":8878.88,"10th_percentile":8878.88,"90th_percentile":8878.88,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":8397.79,"10th_percentile":8397.79,"90th_percentile":8397.79,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4667.51,"10th_percentile":4667.51,"90th_percentile":4667.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":6767.12,"10th_percentile":6767.12,"90th_percentile":6767.12,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":823.61,"10th_percentile":823.61,"90th_percentile":823.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":884.9,"10th_percentile":884.9,"90th_percentile":1193.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":356.1,"10th_percentile":356.1,"90th_percentile":356.1,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":5690.38,"10th_percentile":5690.38,"90th_percentile":6567.57,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":3959.76,"10th_percentile":3959.76,"90th_percentile":3959.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":16793.09,"10th_percentile":16793.09,"90th_percentile":16793.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4932.9,"10th_percentile":4932.9,"90th_percentile":4932.9,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":2778.08,"10th_percentile":1078.0,"90th_percentile":4550.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3054.33,"10th_percentile":3054.33,"90th_percentile":3055.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":1139.12,"10th_percentile":1139.12,"90th_percentile":1139.12,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1474.88,"10th_percentile":1474.88,"90th_percentile":1474.88,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":15241.94,"10th_percentile":15241.94,"90th_percentile":15241.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6982.69,"10th_percentile":4793.26,"90th_percentile":8358.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":9984.0,"10th_percentile":9984.0,"90th_percentile":9984.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":31244.84,"10th_percentile":31244.84,"90th_percentile":31244.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":10613.07,"10th_percentile":10613.07,"90th_percentile":10613.07,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4554.85,"10th_percentile":4552.52,"90th_percentile":4554.85,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":5007.77,"10th_percentile":5007.77,"90th_percentile":5007.77,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":7434.39,"10th_percentile":7434.39,"90th_percentile":7434.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":16042.33,"10th_percentile":13236.11,"90th_percentile":26184.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6314.59,"10th_percentile":6314.59,"90th_percentile":7031.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":26825.86,"10th_percentile":26825.86,"90th_percentile":26825.86,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":32931.75,"10th_percentile":32931.75,"90th_percentile":32931.75,"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 Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":14448.86,"10th_percentile":11582.92,"90th_percentile":18050.86,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":48903.31,"10th_percentile":48903.31,"90th_percentile":48903.31,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":25800.74,"10th_percentile":25800.74,"90th_percentile":35835.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":73320.65,"10th_percentile":73320.65,"90th_percentile":73320.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":25121.94,"10th_percentile":25044.88,"90th_percentile":27466.66,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":30459.02,"10th_percentile":30459.02,"90th_percentile":30459.02,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":74508.9,"10th_percentile":74508.9,"90th_percentile":80719.74,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":23452.62,"10th_percentile":23452.62,"90th_percentile":23452.62,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Musculoskeletal Procedures","code_information":[{"code":"5116","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":38469.48,"10th_percentile":38469.48,"90th_percentile":38469.48,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":9043.7,"10th_percentile":9043.7,"90th_percentile":9043.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5844.8,"10th_percentile":5417.99,"90th_percentile":8846.65,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":19278.68,"10th_percentile":19278.68,"90th_percentile":19278.68,"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":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":11075.75,"10th_percentile":11075.75,"90th_percentile":11075.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":30293.97,"10th_percentile":30293.97,"90th_percentile":30293.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":8364.74,"10th_percentile":7163.17,"90th_percentile":9808.81,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":5318.37,"10th_percentile":5140.38,"90th_percentile":8017.81,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":26429.02,"10th_percentile":26429.02,"90th_percentile":26429.02,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Vascular Procedures","code_information":[{"code":"5184","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":12817.6,"10th_percentile":11864.69,"90th_percentile":15472.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":19458.67,"10th_percentile":19458.67,"90th_percentile":19458.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":16596.65,"10th_percentile":16596.65,"90th_percentile":16596.65,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":14170.65,"10th_percentile":14170.65,"90th_percentile":14170.65,"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."}]}]},{"description":"Level 2 Endovascular Procedures","code_information":[{"code":"5192","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":21028.16,"10th_percentile":21028.16,"90th_percentile":21028.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":11019.19,"10th_percentile":11019.19,"90th_percentile":11019.19,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Endovascular Procedures","code_information":[{"code":"5193","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":17388.72,"10th_percentile":17388.72,"90th_percentile":17388.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4163.0,"10th_percentile":4163.0,"90th_percentile":4163.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2984.34,"10th_percentile":2984.34,"90th_percentile":2984.34,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":8377.82,"10th_percentile":7569.68,"90th_percentile":11730.95,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3445.26,"10th_percentile":3436.48,"90th_percentile":5407.86,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":13356.33,"10th_percentile":8631.21,"90th_percentile":14711.57,"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 Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":3653.6,"10th_percentile":3653.6,"90th_percentile":3653.6,"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 Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":21087.71,"10th_percentile":21087.71,"90th_percentile":21087.71,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":10859.47,"10th_percentile":10859.47,"90th_percentile":10998.53,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"22","median_amount":2053.7,"10th_percentile":2052.65,"90th_percentile":2097.44,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1431.05,"10th_percentile":1431.05,"90th_percentile":2308.36,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":11566.75,"10th_percentile":11230.05,"90th_percentile":13955.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3258.1,"10th_percentile":3258.1,"90th_percentile":5873.42,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":6307.35,"10th_percentile":6307.35,"90th_percentile":6307.35,"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."}]}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":19874.57,"10th_percentile":19874.57,"90th_percentile":19874.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":2259.07,"10th_percentile":2259.07,"90th_percentile":2259.07,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":7663.35,"10th_percentile":6700.54,"90th_percentile":8331.65,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4111.72,"10th_percentile":3967.53,"90th_percentile":4198.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4567.0,"10th_percentile":4347.0,"90th_percentile":5845.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":12785.21,"10th_percentile":12080.33,"90th_percentile":13458.92,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":7445.42,"10th_percentile":6414.21,"90th_percentile":7552.92,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3147.36,"10th_percentile":3147.36,"90th_percentile":3177.13,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"12","median_amount":2098.51,"10th_percentile":2097.44,"90th_percentile":2098.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"11","median_amount":8066.65,"10th_percentile":7482.86,"90th_percentile":8839.71,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3839.25,"10th_percentile":3839.25,"90th_percentile":3839.25,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"27","median_amount":8080.63,"10th_percentile":7198.38,"90th_percentile":13813.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"18","median_amount":3825.3,"10th_percentile":3475.85,"90th_percentile":6386.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":8106.16,"10th_percentile":7917.04,"90th_percentile":15948.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":7589.04,"10th_percentile":5687.54,"90th_percentile":10802.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":17917.41,"10th_percentile":14636.05,"90th_percentile":18863.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":8269.0,"10th_percentile":7383.92,"90th_percentile":11192.06,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5407.11,"10th_percentile":3519.18,"90th_percentile":9565.99,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"60","median_amount":2098.51,"10th_percentile":2097.44,"90th_percentile":2098.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":2308.36,"10th_percentile":2308.36,"90th_percentile":2308.36,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"20","median_amount":8890.65,"10th_percentile":8083.15,"90th_percentile":14118.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3994.0,"10th_percentile":3808.46,"90th_percentile":5639.14,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":7446.29,"10th_percentile":7446.29,"90th_percentile":7446.29,"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."}]}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":5158.39,"10th_percentile":5158.39,"90th_percentile":5158.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":10002.84,"10th_percentile":10002.84,"90th_percentile":10002.84,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":20073.68,"10th_percentile":20073.68,"90th_percentile":20073.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":10389.44,"10th_percentile":10389.44,"90th_percentile":10389.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4616.38,"10th_percentile":4616.38,"90th_percentile":4616.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6534.4,"10th_percentile":6534.4,"90th_percentile":6534.4,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":8237.07,"10th_percentile":8237.07,"90th_percentile":8237.07,"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."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":14348.65,"10th_percentile":13185.77,"90th_percentile":24356.88,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":8229.16,"10th_percentile":6164.4,"90th_percentile":12272.08,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":17498.25,"10th_percentile":17498.25,"90th_percentile":44012.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":19180.0,"10th_percentile":19180.0,"90th_percentile":19180.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":35390.45,"10th_percentile":33976.93,"90th_percentile":45019.83,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":13306.61,"10th_percentile":13306.61,"90th_percentile":13306.61,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":10074.73,"10th_percentile":10074.73,"90th_percentile":10074.73,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"12","median_amount":8584.72,"10th_percentile":7311.21,"90th_percentile":11255.14,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":8042.33,"10th_percentile":8042.33,"90th_percentile":12543.99,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"14","median_amount":18566.35,"10th_percentile":9178.39,"90th_percentile":23365.04,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":16746.83,"10th_percentile":16746.83,"90th_percentile":16746.83,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":14541.3,"10th_percentile":14541.3,"90th_percentile":14541.3,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Urology and Related Services","code_information":[{"code":"5372","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":8269.0,"10th_percentile":8269.0,"90th_percentile":8269.0,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3313.9,"10th_percentile":3313.9,"90th_percentile":3313.9,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3645.29,"10th_percentile":3645.29,"90th_percentile":3645.29,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":8563.1,"10th_percentile":8563.1,"90th_percentile":8563.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2844.65,"10th_percentile":2844.65,"90th_percentile":3535.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":15557.03,"10th_percentile":15557.03,"90th_percentile":15557.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":8269.0,"10th_percentile":8269.0,"90th_percentile":8269.0,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2967.11,"10th_percentile":2967.11,"90th_percentile":2967.11,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4283.11,"10th_percentile":4283.11,"90th_percentile":4283.11,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":5542.55,"10th_percentile":5542.55,"90th_percentile":5542.55,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":8057.93,"10th_percentile":8057.93,"90th_percentile":8057.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2682.78,"10th_percentile":2682.78,"90th_percentile":2682.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Urology and Related Services","code_information":[{"code":"5374","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":31711.27,"10th_percentile":31711.27,"90th_percentile":31711.27,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6208.5,"10th_percentile":6208.5,"90th_percentile":6208.5,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":9957.08,"10th_percentile":9957.08,"90th_percentile":9957.08,"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 Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":12328.28,"10th_percentile":12328.28,"90th_percentile":12328.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3315.59,"10th_percentile":3315.59,"90th_percentile":4973.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":6781.26,"10th_percentile":6781.26,"90th_percentile":6781.26,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":18733.71,"10th_percentile":18128.63,"90th_percentile":22038.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":14242.66,"10th_percentile":12515.91,"90th_percentile":14580.43,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":32219.58,"10th_percentile":32219.58,"90th_percentile":32219.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":15878.68,"10th_percentile":15878.68,"90th_percentile":15878.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":26421.16,"10th_percentile":26421.16,"90th_percentile":26421.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":8633.65,"10th_percentile":8633.65,"90th_percentile":8633.65,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":9497.02,"10th_percentile":9497.02,"90th_percentile":9497.02,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":47629.3,"10th_percentile":47629.3,"90th_percentile":47629.3,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5674.0,"10th_percentile":5674.0,"90th_percentile":5674.0,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":5640.0,"10th_percentile":5640.0,"90th_percentile":5640.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":14150.78,"10th_percentile":11368.5,"90th_percentile":22511.06,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":12552.93,"10th_percentile":12552.93,"90th_percentile":12552.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":5244.89,"10th_percentile":5244.89,"90th_percentile":5244.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":4949.07,"10th_percentile":4949.07,"90th_percentile":5069.57,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2789.93,"10th_percentile":2789.93,"90th_percentile":2789.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"1 through 10","median_amount":11377.08,"10th_percentile":11377.08,"90th_percentile":11377.08,"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":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":11164.84,"10th_percentile":10958.98,"90th_percentile":12137.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Gynecologic Procedures","code_information":[{"code":"5415","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":9798.8,"10th_percentile":9798.8,"90th_percentile":9798.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":10994.3,"10th_percentile":10994.3,"90th_percentile":10994.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":48772.18,"10th_percentile":45223.95,"90th_percentile":67745.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":10880.38,"10th_percentile":10880.38,"90th_percentile":10880.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":5916.59,"10th_percentile":5916.59,"90th_percentile":11896.48,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":19447.98,"10th_percentile":19447.98,"90th_percentile":26126.5,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":15243.9,"10th_percentile":15243.9,"90th_percentile":15243.9,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Gynecologic Procedures","code_information":[{"code":"5416","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":15920.38,"10th_percentile":15920.38,"90th_percentile":15920.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4003.98,"10th_percentile":4003.98,"90th_percentile":4003.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":8269.0,"10th_percentile":8269.0,"90th_percentile":8269.0,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4027.88,"10th_percentile":4027.88,"90th_percentile":4027.88,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":2867.08,"10th_percentile":2867.08,"90th_percentile":2867.08,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":3153.79,"10th_percentile":3152.18,"90th_percentile":3153.79,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":13231.01,"10th_percentile":13231.01,"90th_percentile":13231.01,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":2332.91,"10th_percentile":2332.91,"90th_percentile":2332.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1274.2,"10th_percentile":1274.2,"90th_percentile":5593.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":474.3,"10th_percentile":338.91,"90th_percentile":530.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":347.88,"10th_percentile":347.88,"90th_percentile":347.88,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":877.91,"10th_percentile":849.47,"90th_percentile":898.1,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":965.7,"10th_percentile":965.7,"90th_percentile":965.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":1670.55,"10th_percentile":1670.55,"90th_percentile":1670.55,"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":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":509.52,"10th_percentile":509.52,"90th_percentile":509.52,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":1183.37,"10th_percentile":1183.37,"90th_percentile":1183.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1522.9,"10th_percentile":1522.9,"90th_percentile":1522.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1124.31,"10th_percentile":1124.31,"90th_percentile":1124.31,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1626.75,"10th_percentile":1626.75,"90th_percentile":1626.75,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1627.62,"10th_percentile":1627.62,"90th_percentile":1627.62,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":1291.3,"10th_percentile":1291.3,"90th_percentile":1291.3,"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."}]}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":615.99,"10th_percentile":615.99,"90th_percentile":1758.23,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":2440.13,"10th_percentile":2440.13,"90th_percentile":2440.13,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1615.57,"10th_percentile":1615.57,"90th_percentile":1615.57,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":1021.38,"10th_percentile":1021.38,"90th_percentile":1021.38,"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":"Level 1 Neurostimulator and Related Procedures","code_information":[{"code":"5461","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4983.75,"10th_percentile":4983.75,"90th_percentile":4983.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Neurostimulator and Related Procedures","code_information":[{"code":"5464","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":13090.2,"10th_percentile":13090.2,"90th_percentile":13090.2,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Intraocular Procedures","code_information":[{"code":"5491","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":7320.12,"10th_percentile":7320.12,"90th_percentile":7320.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"12","median_amount":4567.26,"10th_percentile":4352.53,"90th_percentile":5243.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":980.99,"10th_percentile":980.99,"90th_percentile":980.99,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4337.04,"10th_percentile":4075.33,"90th_percentile":4626.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":10126.07,"10th_percentile":9869.13,"90th_percentile":11968.72,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":4424.87,"10th_percentile":4273.21,"90th_percentile":4827.74,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":4188.8,"10th_percentile":4188.8,"90th_percentile":4188.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":194.06,"10th_percentile":173.27,"90th_percentile":41529.43,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"46","median_amount":119.97,"10th_percentile":76.4,"90th_percentile":253.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":308.25,"10th_percentile":308.25,"90th_percentile":685.05,"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 Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":141.4,"10th_percentile":105.78,"90th_percentile":149.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":428.48,"10th_percentile":401.31,"90th_percentile":1149.27,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"13","median_amount":223.75,"10th_percentile":152.81,"90th_percentile":339.22,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"14","median_amount":148.41,"10th_percentile":100.74,"90th_percentile":285.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"60","median_amount":119.58,"10th_percentile":119.52,"90th_percentile":162.56,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"19","median_amount":131.54,"10th_percentile":131.47,"90th_percentile":159.88,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":242.02,"10th_percentile":242.02,"90th_percentile":242.02,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"19","median_amount":286.06,"10th_percentile":180.09,"90th_percentile":696.33,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"16","median_amount":121.36,"10th_percentile":76.4,"90th_percentile":284.18,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":145.32,"10th_percentile":100.59,"90th_percentile":147.0,"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."}]}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"20","median_amount":768.4,"10th_percentile":223.47,"90th_percentile":1176.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"46","median_amount":396.51,"10th_percentile":172.1,"90th_percentile":684.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":751.0,"10th_percentile":751.0,"90th_percentile":751.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":866.0,"10th_percentile":733.14,"90th_percentile":2416.68,"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":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":1371.75,"10th_percentile":593.94,"90th_percentile":2416.68,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"19","median_amount":1037.85,"10th_percentile":378.71,"90th_percentile":1798.64,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":217.19,"10th_percentile":217.19,"90th_percentile":217.19,"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":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":235.79,"10th_percentile":235.79,"90th_percentile":235.79,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"25","median_amount":416.33,"10th_percentile":248.25,"90th_percentile":849.76,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"117","median_amount":227.24,"10th_percentile":119.58,"90th_percentile":591.34,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"41","median_amount":256.01,"10th_percentile":131.54,"90th_percentile":650.13,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":219.16,"10th_percentile":219.16,"90th_percentile":219.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":835.25,"10th_percentile":835.25,"90th_percentile":835.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"37","median_amount":1137.96,"10th_percentile":260.14,"90th_percentile":2049.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"19","median_amount":396.51,"10th_percentile":93.25,"90th_percentile":995.57,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":493.09,"10th_percentile":310.41,"90th_percentile":650.53,"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."}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1023.08,"10th_percentile":917.41,"90th_percentile":1168.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"22","median_amount":479.78,"10th_percentile":273.95,"90th_percentile":1785.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":816.05,"10th_percentile":816.05,"90th_percentile":816.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1175.97,"10th_percentile":830.72,"90th_percentile":3392.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1713.49,"10th_percentile":747.65,"90th_percentile":5951.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":1500.0,"10th_percentile":1405.06,"90th_percentile":3099.06,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1724.41,"10th_percentile":1724.41,"90th_percentile":1724.41,"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":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":490.89,"10th_percentile":490.89,"90th_percentile":490.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"19","median_amount":491.74,"10th_percentile":306.61,"90th_percentile":1749.68,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"23","median_amount":591.34,"10th_percentile":358.41,"90th_percentile":647.31,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":712.04,"10th_percentile":712.04,"90th_percentile":712.04,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":464.43,"10th_percentile":464.43,"90th_percentile":464.43,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":3927.86,"10th_percentile":3927.86,"90th_percentile":4133.06,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1333.09,"10th_percentile":280.74,"90th_percentile":1666.36,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1288.28,"10th_percentile":1288.28,"90th_percentile":1288.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"19","median_amount":581.67,"10th_percentile":559.95,"90th_percentile":964.57,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":1012.01,"10th_percentile":1012.01,"90th_percentile":1012.01,"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 Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":933.24,"10th_percentile":933.24,"90th_percentile":933.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":2028.78,"10th_percentile":2028.78,"90th_percentile":2198.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":1330.88,"10th_percentile":1330.88,"90th_percentile":1330.88,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":556.7,"10th_percentile":521.04,"90th_percentile":559.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"25","median_amount":922.1,"10th_percentile":922.1,"90th_percentile":922.1,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1014.31,"10th_percentile":1014.31,"90th_percentile":1139.29,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":557.18,"10th_percentile":557.18,"90th_percentile":557.18,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":1338.99,"10th_percentile":1071.19,"90th_percentile":1338.99,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":568.06,"10th_percentile":568.06,"90th_percentile":568.06,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":663.58,"10th_percentile":663.58,"90th_percentile":663.58,"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."}]}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1215.57,"10th_percentile":1215.57,"90th_percentile":1215.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"19","median_amount":888.42,"10th_percentile":495.98,"90th_percentile":2573.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":848.92,"10th_percentile":848.92,"90th_percentile":848.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":2501.82,"10th_percentile":2501.82,"90th_percentile":3417.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":9275.67,"10th_percentile":2548.04,"90th_percentile":14589.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":1780.13,"10th_percentile":1780.13,"90th_percentile":1780.13,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1388.95,"10th_percentile":587.57,"90th_percentile":3252.14,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":647.31,"10th_percentile":582.28,"90th_percentile":1448.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":869.99,"10th_percentile":869.99,"90th_percentile":968.05,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2463.75,"10th_percentile":2463.75,"90th_percentile":2463.75,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":3214.07,"10th_percentile":2469.68,"90th_percentile":6743.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2334.56,"10th_percentile":2334.56,"90th_percentile":2645.0,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","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":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1014.82,"10th_percentile":1014.82,"90th_percentile":1014.82,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"13","median_amount":2023.37,"10th_percentile":1938.37,"90th_percentile":2557.34,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":630.05,"10th_percentile":630.05,"90th_percentile":630.05,"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 Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":3254.62,"10th_percentile":3075.83,"90th_percentile":3419.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":7528.63,"10th_percentile":7002.11,"90th_percentile":10798.83,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":1500.0,"10th_percentile":1496.07,"90th_percentile":1500.0,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2068.0,"10th_percentile":1239.37,"90th_percentile":3291.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"22","median_amount":647.31,"10th_percentile":646.98,"90th_percentile":673.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":712.04,"10th_percentile":712.04,"90th_percentile":2767.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"14","median_amount":4959.63,"10th_percentile":3478.22,"90th_percentile":7220.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3347.09,"10th_percentile":3347.09,"90th_percentile":3347.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"1 through 10","median_amount":2784.33,"10th_percentile":2784.33,"90th_percentile":2784.33,"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."}]}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":6065.49,"10th_percentile":6065.49,"90th_percentile":6065.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":922.1,"10th_percentile":922.1,"90th_percentile":922.1,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":6840.6,"10th_percentile":6840.6,"90th_percentile":6840.6,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2290.89,"10th_percentile":2290.89,"90th_percentile":2290.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":14732.4,"10th_percentile":14732.4,"90th_percentile":14732.4,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1706.87,"10th_percentile":1706.87,"90th_percentile":1706.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":2171.69,"10th_percentile":2171.69,"90th_percentile":2171.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":528.0,"10th_percentile":528.0,"90th_percentile":528.0,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":967.56,"10th_percentile":967.56,"90th_percentile":6080.34,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":60305.95,"10th_percentile":60305.95,"90th_percentile":60305.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":814.15,"10th_percentile":814.15,"90th_percentile":1612.26,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"16","median_amount":499.38,"10th_percentile":499.38,"90th_percentile":998.76,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":1050.05,"10th_percentile":1050.05,"90th_percentile":1050.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1620.29,"10th_percentile":1620.29,"90th_percentile":19419.83,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":982.16,"10th_percentile":538.27,"90th_percentile":46708.65,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":2230.17,"10th_percentile":406.77,"90th_percentile":94116.02,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":3578.4,"10th_percentile":3126.18,"90th_percentile":3867.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":339.12,"10th_percentile":339.12,"90th_percentile":339.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":213.62,"10th_percentile":210.57,"90th_percentile":581.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":393.06,"10th_percentile":393.06,"90th_percentile":393.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":762.93,"10th_percentile":762.93,"90th_percentile":762.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":210.25,"10th_percentile":210.25,"90th_percentile":210.25,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":352.94,"10th_percentile":352.76,"90th_percentile":352.94,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":18049.74,"10th_percentile":18049.74,"90th_percentile":18049.74,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":503.53,"10th_percentile":503.53,"90th_percentile":503.53,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":63.62,"10th_percentile":63.62,"90th_percentile":63.62,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":428.87,"10th_percentile":428.87,"90th_percentile":428.87,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":334.19,"10th_percentile":334.19,"90th_percentile":334.19,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1231.89,"10th_percentile":1231.89,"90th_percentile":1231.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":1002.34,"10th_percentile":1002.34,"90th_percentile":1002.34,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"13","median_amount":452.03,"10th_percentile":390.93,"90th_percentile":679.49,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":1985.89,"10th_percentile":1985.89,"90th_percentile":1985.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":407.95,"10th_percentile":407.95,"90th_percentile":407.95,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Diagnostic Tests and Related Services","code_information":[{"code":"5723","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":479.17,"10th_percentile":479.17,"90th_percentile":479.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":660.91,"10th_percentile":660.91,"90th_percentile":660.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":150.6,"10th_percentile":66.33,"90th_percentile":160.72,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":40.0,"10th_percentile":40.0,"90th_percentile":40.0,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"30","median_amount":62.55,"10th_percentile":62.55,"90th_percentile":62.55,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":49.09,"10th_percentile":49.09,"90th_percentile":49.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":54.0,"10th_percentile":54.0,"90th_percentile":54.0,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":55.15,"10th_percentile":55.15,"90th_percentile":55.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":63.83,"10th_percentile":48.83,"90th_percentile":63.83,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":239.93,"10th_percentile":239.93,"90th_percentile":239.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":164.89,"10th_percentile":164.89,"90th_percentile":164.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4511.21,"10th_percentile":4511.21,"90th_percentile":4511.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":271.33,"10th_percentile":271.33,"90th_percentile":271.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":3401.31,"10th_percentile":3401.31,"90th_percentile":3401.31,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":162.5,"10th_percentile":162.5,"90th_percentile":162.5,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":54.75,"10th_percentile":54.72,"90th_percentile":70.35,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":60.23,"10th_percentile":60.23,"90th_percentile":60.23,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":179.08,"10th_percentile":179.08,"90th_percentile":179.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":223.57,"10th_percentile":223.57,"90th_percentile":223.57,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":89.21,"10th_percentile":89.21,"90th_percentile":89.21,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":235.52,"10th_percentile":235.52,"90th_percentile":235.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":318.62,"10th_percentile":318.62,"90th_percentile":318.62,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":104.92,"10th_percentile":102.62,"90th_percentile":646.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":232.74,"10th_percentile":232.62,"90th_percentile":232.74,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":255.88,"10th_percentile":255.88,"90th_percentile":255.88,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":877.0,"10th_percentile":877.0,"90th_percentile":877.0,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":89.21,"10th_percentile":89.21,"90th_percentile":160.84,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"19","median_amount":257.91,"10th_percentile":254.46,"90th_percentile":257.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"13","median_amount":92.61,"10th_percentile":79.94,"90th_percentile":559.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":290.12,"10th_percentile":201.0,"90th_percentile":804.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":594.72,"10th_percentile":594.72,"90th_percentile":594.72,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":358.23,"10th_percentile":238.82,"90th_percentile":959.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":379.33,"10th_percentile":189.98,"90th_percentile":774.64,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"17","median_amount":238.07,"10th_percentile":233.07,"90th_percentile":268.07,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":203.08,"10th_percentile":101.54,"90th_percentile":889.5,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Health and Behavior Services","code_information":[{"code":"5821","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":150.6,"10th_percentile":150.6,"90th_percentile":241.79,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":213.68,"10th_percentile":213.68,"90th_percentile":213.68,"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":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, bupivacaine, nos, 0.5mg","code_information":[{"code":"9290","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":5569.76,"10th_percentile":5569.76,"90th_percentile":5569.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":1612.05,"10th_percentile":1612.05,"90th_percentile":1612.05,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":84.27,"10th_percentile":71.63,"90th_percentile":94.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":84.27,"10th_percentile":74.27,"90th_percentile":122.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":148.64,"10th_percentile":148.64,"90th_percentile":148.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"1 through 10","median_amount":132.71,"10th_percentile":132.71,"90th_percentile":132.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"31","median_amount":131.96,"10th_percentile":40.52,"90th_percentile":271.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"363","median_amount":79.28,"10th_percentile":16.33,"90th_percentile":246.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":122.58,"10th_percentile":22.48,"90th_percentile":360.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":46.74,"10th_percentile":33.43,"90th_percentile":84.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"22","median_amount":603.55,"10th_percentile":321.41,"90th_percentile":879.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"22","median_amount":164.12,"10th_percentile":54.83,"90th_percentile":345.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":31.68,"10th_percentile":25.85,"90th_percentile":35.18,"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":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"1 through 10","median_amount":32.36,"10th_percentile":32.36,"90th_percentile":32.36,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"246","median_amount":98.11,"10th_percentile":29.62,"90th_percentile":263.44,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"164","median_amount":25.83,"10th_percentile":7.65,"90th_percentile":73.56,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"71","median_amount":28.41,"10th_percentile":11.26,"90th_percentile":50.31,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"53","median_amount":30.22,"10th_percentile":29.64,"90th_percentile":114.13,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":264.5,"10th_percentile":264.5,"90th_percentile":264.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"181","median_amount":312.2,"10th_percentile":76.2,"90th_percentile":755.31,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"151","median_amount":127.2,"10th_percentile":52.79,"90th_percentile":326.65,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"37","median_amount":167.03,"10th_percentile":51.28,"90th_percentile":349.43,"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":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"15","median_amount":1091.17,"10th_percentile":592.52,"90th_percentile":1937.2,"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":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"69","median_amount":456.36,"10th_percentile":150.36,"90th_percentile":1039.21,"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":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":2518.16,"10th_percentile":2518.16,"90th_percentile":2518.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":938.6,"10th_percentile":596.0,"90th_percentile":1590.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":836.46,"10th_percentile":474.45,"90th_percentile":3247.75,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"11","median_amount":757.11,"10th_percentile":245.32,"90th_percentile":3201.97,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"38","median_amount":384.62,"10th_percentile":128.88,"90th_percentile":925.35,"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":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"56","median_amount":480.32,"10th_percentile":153.54,"90th_percentile":884.56,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"23","median_amount":570.75,"10th_percentile":197.55,"90th_percentile":760.02,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"1 through 10","median_amount":369.74,"10th_percentile":369.74,"90th_percentile":928.63,"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":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"1 through 10","median_amount":1039.86,"10th_percentile":1039.86,"90th_percentile":1039.86,"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":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"35","median_amount":1356.53,"10th_percentile":408.11,"90th_percentile":2772.53,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"30","median_amount":447.22,"10th_percentile":104.05,"90th_percentile":894.25,"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":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"11","median_amount":288.12,"10th_percentile":144.06,"90th_percentile":998.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"1 through 10","median_amount":1373.99,"10th_percentile":703.39,"90th_percentile":2592.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"1 through 10","median_amount":1389.51,"10th_percentile":1079.79,"90th_percentile":3157.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"18","median_amount":1590.0,"10th_percentile":318.0,"90th_percentile":2226.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":3125.68,"10th_percentile":745.58,"90th_percentile":6688.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"1 through 10","median_amount":626.17,"10th_percentile":488.36,"90th_percentile":2366.31,"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":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"66","median_amount":99.56,"10th_percentile":15.6,"90th_percentile":1039.18,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"24","median_amount":159.45,"10th_percentile":17.16,"90th_percentile":867.97,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"1 through 10","median_amount":1910.6,"10th_percentile":1910.6,"90th_percentile":1910.6,"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":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 62.65] [Cardiac Cath (%BC): 63.5] [Laparoscopy (%BC): 60 Maximum Reimbursement 25000] [Observation (%BC): 63.5 Maximum Reimbursement 4000] [Emergency Department (%BC): 45] [CT Scan OP ($): 826] [MRI OP ($): 949] [Radiology (%BC): 63.5] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.65] [Physical Therapy (%BC): 62.65] [Respiratory Services/Therapy  (%BC): 62.65] [Speech Therapy (%BC): 62.65] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 62.65]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Aetna","plan_name":"Qhp Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Medicare payment methodology that is excluded from the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS). Medicare logic based on reasonable costs.]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10715] [Ablation ($): 64765] [Cardiac Cath ($): 22153] [Lithotripsy ($): 29474] [PTCA ($): 41693] [Observation ($): 12633] [ED Level 1--99281 ($): 771] [ED Level 2--99282 ($): 771] [ED Level 3--99283 ($): 2432] [ED Level 4--99284 ($): 4700] [ED Level 5--99285 ($): 4700] [Critical Care-99291 ($): 11465] [Urgent Care ($): 693] [Cardiac Rehabilitation Therapy ($): 249] [Electrophysiology and Mapping Studies ($): 64765] [Sleep Studies-Attended ($): 5242] [Sleep Studies-Unattended ($): 1499] [CT Scan OP ($): 3494] [MRI OP ($): 4342] [Mammography-Diagnostic ($): 523] [Mammography-Screening ($): 523] [Positron Emission Tomography ($): 6787] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 937] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 328] [Physical Therapy ($): 328] [Resp. Services/Therapy ($): 249] [Speech Therapy ($): 328] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7525] [Ablation ($): 55846] [Cardiac Cath ($): 19112] [Lithotripsy ($): 25648] [PTCA ($): 35949] [Observation ($): 11593] [ED Level 1--99281 ($): 697] [ED Level 2--99282 ($): 697] [ED Level 3--99283 ($): 2027] [ED Level 4--99284 ($): 3894] [ED Level 5--99285 ($): 3781] [Critical Care-99291 ($): 10829] [Urgent Care ($): 539] [Cardiac Rehabilitation Therapy ($): 217] [Electrophysiology and Mapping Studies ($): 55846] [Sleep Studies-Attended ($): 4681] [Sleep Studies-Unattended ($): 1249] [CT Scan OP ($): 2884] [MRI OP ($): 3752] [Mammography-Diagnostic ($): 452] [Mammography-Screening ($): 452] [Positron Emission Tomography ($): 5136] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 780] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 277] [Physical Therapy ($): 274] [Resp. Services/Therapy ($): 217] [Speech Therapy ($): 274] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 56] [Cardiac Cath (%BC): 56] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Urgent Care (%BC): 56] [Chemotherapy (%BC): 56] [CT Scan OP ($): 1575.00] [MRI OP ($): 4172.70] [Positron Emission Tomography ($): 6520.50] [Radiology (%BC): 56] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Clear Spring Health","plan_name":"Community Care Alliance Of Il Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Devoted Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 31.2] [OP Surgery  (%BC): 31.2] [Observation (%BC): 31.2] [Emergency Department (%BC): 31.2] [Occupational Therapy (%BC): 31.2] [Physical Therapy (%BC): 31.2] [Respiratory Services/Therapy  (%BC): 31.2] [Speech Therapy (%BC): 31.2] [All Other OP (%BC): 31.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Meridian 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://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://hfs.illinois.gov/medicalproviders/medicaidreimbursement/hospital]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30] [OP Surgery  (%BC): 30] [Observation (%BC): 30] [Emergency Department (%BC): 30] [Occupational Therapy (%BC): 30] [Physical Therapy (%BC): 30] [Respiratory Services/Therapy  (%BC): 30] [Speech Therapy (%BC): 30] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 80] [OP Surgery  (%BC): 80] [Observation (%BC): 80] [Emergency Department (%BC): 80] [Occupational Therapy (%BC): 80] [Physical Therapy (%BC): 80] [Respiratory Services/Therapy  (%BC): 80] [Speech Therapy (%BC): 80] [All Other OP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 57]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 66] [Observation (%BC): 66] [Emergency Department (%BC): 66] [Occupational Therapy (%BC): 66] [Physical Therapy (%BC): 66] [Respiratory Services/Therapy  (%BC): 66] [Speech Therapy (%BC): 66] [All Other OP (%BC): 66]","count":"1 through 10","median_amount":189.51,"10th_percentile":189.51,"90th_percentile":189.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 30]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 30.9] [OP Surgery  (%BC): 30.9] [Observation (%BC): 30.9] [Emergency Department (%BC): 30.9] [Occupational Therapy (%BC): 30.9] [Physical Therapy (%BC): 30.9] [Respiratory Services/Therapy  (%BC): 30.9] [Speech Therapy (%BC): 30.9] [All Other OP (%BC): 30.9]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]}]}